Author Archives: suesspiciousminds

I have written about a few of these cases since Holman J’s decision in December 2014, but this one is rather out of the ordinary.

RY v Southend Borough Council 2015

http://www.bailii.org/ew/cases/EWHC/Fam/2015/2509.html

Hayden J was dealing with two applications. The first was an application by RY, an approved adopter, to adopt a child who is about 2 1/2, a little girl named SL.  The second was the application by the Local Authority  (Southend) to remove the child from RY’s care, under section 35 of the Adoption and Children Act 2002.

Cases about section 35 are rather rare, and this one raises some unusual issues.

First things first, what does s35 say?

“35 Return of child in other cases

(2) Where a child is placed for adoption by an adoption agency, and the agency –

(a) is of the opinion that the child should not remain with the prospective adopters, and

(b) gives notice to them of its opinion, the prospective adopters must, not later than the end of the period of seven days beginning with the giving of the notice, return the child to the agency.

(5) Where –

(a) an adoption agency gives notice under subsection (2) in respect of a child,

(b) before the notice was given, an application for an adoption order (including a Scottish or Northern Irish adoption order), special guardianship order or residence order, or for leave to apply for a special guardianship order or residence order, was made in respect of the child, and

(c) the application (and, in a case where leave is given on an application to apply for a special guardianship order or residence order, the application for the order) has not been disposed of, prospective adopters are not required by virtue of the notice to return the child to the agency unless the court so orders”.

In plain English, where a Local Authority have placed for a child for adoption, if they ask for the child back, the adopter must hand the child back within 7 days.  UNLESS the adopter has already made an application to Court for adoption, or a Special Guardianship Order or a residence order (Child Arrangements Order), in which case it is up to the Court what happens.

In this case, RY had lodged her application to adopt SL BEFORE the LA asked her to hand the child back, so it was for the Court to decide.

By way of important background, SL was a very ill child.

3. At birth SL was pale, floppy and had no respiratory effort or heart rate and required intensive resuscitation. Her first gasp was not until 20 minutes into life. Dr. Daniel Mattison, Consultant Paediatrician, identifies that SL had experienced hypoxic-ischaemic encephalopathy. This can result in a wide spectrum of disability and in SL’s case she has been left with a raft of problems. Firstly, quadriplegic cerebral palsy, which means that she has impaired movement and stiffness of all her limbs as a direct result of brain damage to the parts of the brain involved in movement, tone and posture.
4. Secondly, she has global developmental impairment. Thirdly, she has gastro-oesophageal reflux disease. That is a condition where the stomach contents pass into the oesophagus causing symptoms. The stomach contents are acidic so the symptoms include pain from the acidic contents coming into contact with the oesophagus and the throat. They also include vomiting, feeding difficulties and respiratory problems if the stomach contents irritate the top of the windpipe or if small amounts enter the lungs. Gastro-oesophageal reflux disease is more common and may be more severe in children with severe neuro-disability like SL.
5. Finally, Dr. Mattison considers that there is visual impairment as a result of the deprivation of blood and oxygen to those parts of the brain involved in vision.

One can see that absolutely anyone would have faced challenges in caring for SL and meeting her needs.

What the Judge found, by careful consideration of the facts, was that the matching process of RY and SL was optimistic.

RY had some considerable issues of her own, having been diagnosed with Ehler-Danloss syndrome, occasionally needing to feed herself through a gastrostomy tube and being in a power chair needing to use hoists to move herself out of the chair.  She also stated that she had been diagnosed with Asperger’s Syndrome when she was 19.

None of that, of course, means that she is excluded from being a carer for a child, or from being an adopter, but it does mean that there were medical issues that needed some careful consideration in the assessment and matching process.

The fact that the assessment process identified that there had been views that RY’s physical problems were emotional or psychological in nature, at the very least ought to have meant that the adopter’s medical records would have been needed to be seen and commented on by a medically qualified professional.

I am not myself at all clear as to why that wasn’t the case.

12…the assessment report more generally – poses a number of questions. Most importantly, it does not address RY’s capacity physically to parent a disabled youngster as the child got older and heavier. It also has to be said that the possibility that RY’s health difficulties might have a psychological component were evident. It is easy, of course, to be wise with the benefit of hindsight, but nonetheless it seems to me that the enquiries made into RY’s physical and mental health were less than satisfactory.

13. A number of reports were requested, including one from RY’s general practitioner and rheumatologist, but the nature of that enquiry appears to have been very limited and as RY on her own account has had very little recent contact with either in recent years, it is not surprising that little constructive information was forthcoming.
14. Ms. Frances Heaton QC and Mr. Shaun Spencer, who appear on behalf of Southend Borough Council, absorb this criticism without demure. In their closing submissions they state as follows: ^
    

    “With regard to its own failure to consider these records, the adoption agency is cognisant of the fact that although not signposted in the regulations, a review of RY’s medical records is likely to have been beneficial during the adoption process”.

15. They continue:
    

    “Where an adoption agency has referred a proposed placement to the adoption panel, the panel must consider the proposed placement and make a recommendation to the agency as to whether the child should be placed for adoption with that particular prospective adopter pursuant to regulation 32(1) of the Adoption Act Regulations 2005.

    In considering what recommendation to make the panel, (1), must have regard to the statutory duties imposed on the agency; (2), must consider and take into account all information and reports ^ passage of it; (3), may request the agency to obtain any other relevant information which the Panel considers necessary; and (4), may obtain legal advice as it considers necessary in relation to the case. Thereafter, in coming to a decision about whether a child should be placed for adoption with a particular prospective adopter, the agency decision maker must take into account the recommendation of the adoption panel and have regard to the child’s continuing welfare, pursuant to regulation 34(4) of the Adoption Act Regulations 2005″.

• 16.Ms. Heaton and Mr. Spencer also identified the most recent Department of Education Statutory Guidance on Adoption, July 2013, drawing my attention particularly to para.4.15, which states:

   

  1. 1. “Agencies have a duty to satisfy themselves that prospective adopters have a reasonable expectation of continuing to enjoy good health. The medical adviser should explain and interpret health information from the prospective adopter, their GP, and consultants if relevant, to facilitate panel discussion. The opinion of the prospective adopter’s GP and the agency’s medical adviser about the health status of the prospective adopter needs to be given sufficient weight by adoption panels and agency decision-makers. Mild chronic conditions are unlikely to preclude people from adopting, provided that the condition does not place the child at risk through an inability to protect the child from commonplace hazards or limit them in providing children with a range of beneficial experiences and opportunities. More severe conditions must raise a question about the suitability of a prospective adopter, but each case will have to be considered on its own facts …”

That seems to me very clear that an adoption medical of the prospective adopter would be required and that in a case where medical issues arise, the records would be needed.

This next part, for my mind, is the most worrying aspect of the case  – that these important aspects had not been properly considered because of the pressures on Southend (and one assumes other Local Authorities) to move adoptions through the system quickly to satisfy the Government driven statistics. But even more seriously, that where a Local Authority does not properly satisfy the Government as to performance, there are ‘penalties’

I have to be candid, I do work for a Local Authority. I don’t know about penalties for failure to meet the thoughts that Central Government have about performance (and frankly I wouldn’t know how to find out). The common-sense reading of this portion is that there are financial implications for a Local Authority who doesn’t get their adoptions through as quickly as Central Government thinks that they should.  Perhaps that is right, in which case it would be very worrying.  Perhaps someone has got the wrong end of the stick here.

17. Counsel seek to explain the deficiencies of this agency’s process in these terms, they state:
    

    “The agency appreciates the strength of an argument that it failed to have sufficient regard to the matters required of it both by the regulations and the statutory guidance. In the context of that argument, the court understands the pressures on agencies quickly to match children with approved adopters as a result of government measures”.

18. Ms. Heaton and Mr. Spencer say:
    

    “It is a reality of the situation that adoption agencies are being judged and measured by government departments on the speed of time taken to match children, poor performance leads to penalties”.

19. They conclude:
    

    “This adoption agency recognises that these pressures may have resulted in proper scrutiny not being fully implemented in this case. I am offered reassurance that the agency recognises that a request to consider our wide medical records would have been beneficial to the matching process. I have been told that they intend to address this failing for the future by ensuring that the agency is more ready to be resistant to pressures and to identify at an early stage those cases which it considers to be exceptional where a ‘longer matching process is required’.”

The Judge was also perturbed about this :-

21. I am not in any way in any position to evaluate the explanation proffered in the authority’s fulsome explanation. I was not, for example, aware that government departments were subjected to penalties where there had been too much delay in the time taken to match children, I confine myself entirely to observing what is little more than a statement of that which should be obvious.
22. Children like SL are profoundly vulnerable. Social services and society more generally must be sedulous in its protection of them. The fact that there may be fewer welfare options available for such children must never mean the criteria for matching carers to them can ever be compromised. On the contrary, the obligations should be seen as even more rigorous. The matching of RY to SL was undoubtedly ambitious.

In any event, things became more serious, because what was asserted was that RY’s care was not merely deficient but actually harmful and indeed that the care of SL had reached the point where significant harm had been caused.

There were many issues in this regard, and the Judge was also critical that the document provided to RY that set out what portions of parental responsibility she was allowed to exercise and what she was not was a stock document and was ambiguous

32. What is contemplated here is the granting of some but not all parental rights. The focus is on the child with the objective of permitting the prospective adopter to take day-to-day decisions in the sphere of health, education, religion, holidays and social activities. Here this local authority, in common with many others, I am told, issued a standardised pro forma document.
33. In relation to health issues, it permitted RY to consent to emergency medical treatment. It did not permit her to consent to treatment including operations that require anaesthetic. It did permit her to take decisions in relation to any prophylactic treatment, including immunisations, decisions in relation to involvement in counselling or therapeutic services, agreement to school medical appointments and decisions in relation to dental treatment. It also provided for her to have decision making responsibility across a range of issues relating to education, day-care, religion, holidays and contact, had that been relevant. I need not look at those wider issues and I concentrate entirely, because it is in focus here, on the provisions relating to health. I have, to say the least, been greatly exercised by them. They are not to my mind a model of pellucid clarity.
34. There has been much confusion by the professionals as to what the scope and ambit of RY’s parental responsibility powers in fact were. Having read the document I am not surprised. This document, particularly if it is, as I am told, issued widely, really requires refinement. Again I am reassured that Ms. Heaton has this in her sights. She submits that the adoption agency recognises that on reflection and with the benefit of hindsight, (a recurrent phrase) the use of this local pro forma document was not suited to the facts of this case. It is now, she says, recognised that what was required – and is likely to be required in cases such as this concerning any child with complex care needs – is “a bespoke s.25 parental responsibility document tailored to the individual circumstances and needs of the child being placed.”
35. She goes on to offer the reassurance that in the light of this acknowledgement this Adoption Agency intends to review its own practices and procedures in relation to the identification of appropriate restriction on parental responsibility and to introduce bespoke PR documents in appropriate cases. It also intends to raise the issue with the British Association of Adoption and Fostering so that other adoption agencies may benefit from learning from the experience of this case. I would add to that my own view that the standardised document is itself lacking in clarity. The first two requirements permitting consent for emergency treatment and refusing to bestow consent to treatment including operations are not immediately capable of easy reconciliation and generate, to my mind, inevitable confusion. As I have said, they require some refinement though, of course, I recognise, in many cases, issues such as this will simply not arise.

The crux of this case was as to how RY behaved whilst SL was in hospital, which sadly given SL’s considerable health needs was something that happened often and would be likely to happen in the future. It was asserted that she was obstructive about the child’s feeding, resistant to medical advice, over-reporting of medical concerns, requested sedation for the child, adminstered oxygen when she was not trained to do so and discharged the child against medical advice.

59. The local authority’s schedule posits six findings and four supplemental findings. The first is that during SL’s hospital admission, which commenced on 26 September 2014, RY repeatedly refused nursing observations such as taking blood pressure or temperature. The second is that RY repeatedly refused to allow medical advice in relation to SL’s dietetic requirements. The third is that RY repeatedly stopped or refused medication and treatments. The fourth is that RY demonstrated an inability consistently to accept medical advice. The fifth is that RY repeatedly requested treatments of her own motion or insists on treatment methods. And the sixth is that due to RY’s anxieties, she tends to focus her attention on unnecessary medical procedures or extreme outcomes.
60. The four additions are that RY suctioned SL unnecessarily too vigorously and in an inappropriate manner. Secondly, that she repeatedly requested sedation medication for SL despite being told by at least two health professionals, Dr. Court and Sally Deever, that such may compromise her breathing. The third is that RY gave SL oxygen unnecessarily and inappropriately when she was not trained to do. And fourth, that SL suffered harm in RY’s care and was likely to do so if she were to return to her care. That last finding being essentially a composite of the earlier allegations.
61. As I have already said, it is really a very striking feature of this case that so much of what is set out in that schedule is factually uncontentious. It is the gloss or interpretation that is put on it that has become the focus of disagreement during this case. In, for example, the first finding, namely that during SL’s hospital admission in September 2014 RY repeatedly refused nursing observations, there is agreement that she did indeed make such refusals.

Most of the factual matters, being supported by the medical reports provided by the hospital treating SL, were not in dispute. What was disputed was the interpretation to be placed on them, or whether they amounted to harmful behaviour rather than just genuine concern about a child who was undoubtedly very unwell.

65. RY told me that she derived some satisfaction from the preparation of the food for her daughter that it was instinctive to her to want to do that and that I certainly understand, but as time passed it became all too clear that this preferred method of nutrition not only was unsatisfactory, it was falling manifestly and demonstrably short of meeting SL’s needs. The doctors and nursing staff and dieticians were plainly highly agitated that SL should have good quality calorific and nutritional food, particularly when recovering from her operation, and RY undoubtedly resisted it in the face of her own obviously inadequate regime long after it would have become obvious to the reasonable carer that this was simply not meeting this little girl’s needs.
66. So obvious was it that, in circumstances which I really find to be truly extraordinary, the hospital required RY to sign a waiver abdicating their responsibility to her for providing SL’s proper nutrition. What I find so deeply alarming is that in this instance and in the other instance that I have just looked at, that is to say the failure to let nurses take temperature, blood pressure, routine tests, et cetera, how it was that RY’s will prevailed to the extent it did. I can only assume that her behaviour was as described so bizarre that it caused confusion in the ward and led to poor clinical judgments to be taken contrary to SL’s interests.
67. Ms. Heaton put to RY directly on this point, “In those circumstances, how could RY be said to be putting SL’s interests first?” And to that, in my judgment, RY had no satisfactory answer. I simply do not believe that she has understood or is now able fully to understand why it was she behaves in that way, but there is no satisfactory explanation when properly analysed for this failure to meet that most basic of SL’s needs, her need for nutrition.
68. As I have said, I do not find it necessary to work through each of the many examples contended for in the Scott Schedule of, for example, RY’s refusing medication and treatments, chiefly again because it is not disputed. One such example which stood out to me in the evidence was RY’s refusal to permit SL to take oramorph when moved onto the ward when in the intensive care unit. Oramorph, I was told, is a morphine-based medicine the objective of which was to downscale gradually the pain relief from the higher dosage that she hitherto had been receiving.
69. RY told the hospital – and indeed told me – as Ms. Walker emphasises in her closing submissions, that SL “didn’t need anything for break-through pain”. It is one of a number of responses that causes Ms. Walker to comment on what she contends to be RY’s arrogance towards medical staff for how, says Ms. Walker, could RY possibly have been in a position to gainsay the medical advice and to assert from the basis of no medical knowledge at all and in a highly specialised area of medicine that this little girl did not need anything for break-through pain. Once again it was RY’s wish and not that of the doctors that prevailed. I agree with Ms. Walker that the evidence in relation to this can properly be described, as she does, “overwhelming”.
70. I would also like to highlight the incident set out in the unchallenged statement of Ms. Leanne Mulholland, who is a Senior Sister at the Paediatric Emergency Department at the Royal Manchester Children’s Hospital. In her statement of 7 May 2015, Ms. Mulholland tells me that she was the nurse in charge on the early shift of 14 July. Four areas of concern were handed over to her from the night staff.
71. Firstly, there was the transfer of SL to the Paediatric Emergency Department in RY’s car directly contrary to the advice of the paramedic. A process which in and of itself caused a significant delay in admission as Mr. Unwin emphasises as a convenient forensic illustration of harm. Secondly, on arrival there was concern that RY simply refused initially to allow a full respiratory assessment to be performed. I am still unclear why that was, but it was ultimately completed as it manifestly needed to be. There was reported to Sister Mulholland a concern about the ambit of parental responsibility, which I have already looked at.
72. Then there was the final area of concern; active discharge from the hospital against medical advice. That RY should do this at all, that she should feel knowledgeable and empowered enough to do it, even before she had been granted the Adoption Order and full parental responsibility, is profoundly troubling. This episode illustrates to my mind that RY had gone beyond behaviour that was merely capable of being categorised as bizarre but had, in truth, spiralled out of control. I find her judgment and her behaviour, was irrational, unstable and she had become, I am truly sad to say, a real risk to SL

There really was no way that Hayden J would have been able to grant RY’s application for adoption. He is very kind in his conclusions

80. Ultimately, balancing what I have sought to identify as some really clear, captivating and obvious strengths that RY has and balancing those against the harm I have just outlined in summary, does not present to me a remotely delicate balance in determining the future for SL. The way ahead for her, whatever it may hold, is clear. The risk RY presents of harm or significant harm to SL is so real and serious and the potential consequences so grave that I find them to be wholly inimical to her welfare. It points clearly and determinatively in support of the local authority’s application under s.35(2) in effect refusing return to RY’s care. It follows, therefore, that I dismiss her application for adoption.
81. In my lay view, RY has plainly some real emotional and psychological issues to address. I hope she is able to do so. I hope her family are able to help her to do so. In the meantime, it would not be safe, in my judgment, for her to be involved in the care of any child or vulnerable adult with disabilities.

Transparency

Hayden J recognised that this was a case, where the system had not worked as it should and that a very vulnerable child had been exposed to more harm in the adoptive placement that had been intended to meet her needs, and there was thus a public interest in the case being reported

Cases of this kind generate real public concern and rightly so. In the past a judgment such as this would not have entered the public domain. It is hardly surprising therefore that public understanding of the Family Court process and confidence in it’s system had begun to erode. The Practice Guidance of the 16^th January 2014 was intended to and has achieved immediate and significant change in practice in relation to publication of judgments in the Family Courts and the Court of Protection. In April 2013 Sir James Munby P issued a statement, View From the President’s Chambers: The Process of Reform, [2013] Fam Law 548 in which he identified transparency as one of three central strands of reform which the Family Justice System is currently undergoing. This is an ongoing process in which a balance between freedom of expression, protected by Article 10 ECHR and the rights of vulnerable children to privacy and security, protected by Article 8 is often a delicate one.

The fundamental argument was as to whether RY’s name should be reported.  Unlike a case where identification of a parent who has harmed the child inextricably identifies the child as well, and thus should not happen, here RY and SL did not share a name and identifying RY would not also identify SL.

The Court had come very close to identifying RY in the judgment, and the single factor which mitigated against it was RY’s intention to seek help for her own problems.

88. I have already expressed my clear view that the link between publication of the identity of the carer and any adverse impact upon the child subject to these proceedings is tenuous. However, I think RY’s entitlement to the opportunity of therapeutic support, in private, which gives the process much greater prospects of success is so manifestly in both her own interests and those of society more widely that it weighs heavily in the parallel analysis of competing rights and interests in which the starting point is ‘presumptive parity’.
89. In my judgement the need to protect RY’s privacy while she embarks on what I have no doubt will be a difficult and challenging therapeutic process is to recognise an important aspect of her own autonomy and dignity

That does obviously raise the prospect that in a similar case, where the adopter’s conduct was not as a result of psychological difficulties or there was not a recognition of those difficulties and an intention to seek help, that an adopter who harmed the child could be publicly named in a judgment. There would be reasonable arguments that this would be the right thing to do.